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The CMS-2567 (Statement of Deficiencies) is an official, legal document. All information must remain unchanged except for entering the plan of correction, correction dates, and the signature space. Any discrepancy in the original deficiency citation(s) will be reported to the Dallas Regional Office (RO) for referral to the Office of the Inspector General (OIG) for possible fraud. If information is inadvertently changed by the provider/supplier, the State Survey Agency (SA) should be notified immediately.
An entrance conference was held with the facility chief executive officer on the morning of 10/12/21. The purpose and process of the complaint survey were discussed, and an opportunity given for questions.
An exit conference was held with the facility chief executive officer and quality director on the afternoon of 10/13/21. Preliminary findings of the complaint survey were discussed, and an opportunity given for questions.
Based on the findings of the survey, the facility was non-compliant with the Condition of Participation, 42 CFR 482.42, for Infection Control. Upon surveyor entrance at the facility on 10/12/21, at approximately 8:40 a.m., no individual at the visitor/reception desk, along with erratically functioning covid-19 screening equipment, posed an Immediate Jeopardy to patients, visitors, and staff due to the potential for transmission of the virus.
A plan to abate the Immediate Jeopardy was submitted by the facility on 10/14/21 at 1:13 p.m. The Immediate Jeopardy was removed but the deficient practice continued at the condition level.
The facility abatement plan included the following:
" ...d. A trained staff member was assigned to the visitor desk to screen staff and visitors per CDC guidelines.
e. Cobalt El Paso leadership team walked the facility to ensure that visitors complied with CDC COVID-19 regulations, all visitors and staff were found to comply with the guidelines.
f. COVID-19 Admission Attestation with CDC education provided to all patients present in the building.
g. A written staff schedule was created and implemented for visitor desk screening for coverage during visiting hours and change of shift.
h. In-service initiated 10/12/2021 to educate staff of current CDC guidelines and patient visitation screening procedures.
i. Staff who will be screening visitors and staff were provided with a competency on the use of the screening equipment and form completion.
j. Provided documentation of provided education to staff quarterly starting February 2021, May 2021, and October 2021. Education is provided on employee orientation as well. (Surveyor Note: Please see conflicting statements provided in staff interviews.)
k. Staff are being educated prior to starting their shift, including PRN staff.
l. It is expected that 100% of staff compliance with training will occur on or before October 16, 2021.
m. Daily, the Chief Quality Officer, or her designee, will review the screening sheets and logs for completeness and compliance. This information will be brought forward to the Quality Committee, Medical Executive Committee, and Governing Board, quarterly and then as recommended, from those committees once compliance is met ..."
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